Category Archives: Baseball

All Blogs, Baseball, Elbow, Pitcher's Elbow

Pitchers and Their Elbows

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When reading “Ulnar Collateral Ligament Injuries of the Elbow in the Throwing Athlete” in an orthopedic journal recently, I was struck by how I interpreted best evidence distinctly from the authors.

It’s useful to see each of the original key points next to a suggested rewrite:

Original: “The anterior cord of the ulnar collateral ligament is the portion most commonly injured and is what is reconstructed.”

Rewrite: After years of frequent throwing the anterior band of the medial collateral ligament (MCL) of the elbow can become attenuated and lax. The word “injury” does not apply to most MCL insufficiency.

Original: “The ulnar collateral ligament is under the most stress during the late cocking and early acceleration phases of throwing.”

Rewrite: A notable percentage, if not a majority, of major league pitchers have some MCL insufficiency and valgus extension overload type of elbow arthritis. Instability severe enough to offer surgery is diagnosed on stress radiographs with the patient relaxed.

Original: “Magnetic resonance imaging is necessary to properly diagnose ulnar collateral ligament insufficiency.”

Rewrite: “An acute increase in symptoms can be due to an acute rupture or an episode of increased symptoms from long-standing insufficiency. It’s difficult to distinguish these two possibilities.”

Original: “Reconstruction is the primary treatment method for athletes. The modified Jobe and Docking techniques are the most commonly used operative techniques.”

Rewrite: The role of surgery for lesser degrees of ligament insufficiency is debatable. The desire for reconstruction in relatively young patients with limited instability may be related to psychosocial factors and seems increasingly common. There is a myth that reconstruction of the MCL can help people throw faster, and people often hope that it can get them to a higher level of competition.

Original: “For true acute ruptures of the ligament with ecchymosis and flexor pronator muscle injury, the role of nonoperative treatment, repair, and reconstruction with tendon graft are uncertain. The MCL heals predictably after elbow dislocation and would be expected to heal after isolated rupture as well.”

Rewrite: People with chronic MCL insufficiency have few symptoms in daily life. Athletes that decide to stop pitching may not benefit from ligament repair.

Original: “Athletes are able to return to competition, on average, between 12 and 20 months after the procedure with typically excellent outcomes.”

Rewrite: A notable percentage of athletes do not return to their prior level of competition after MCL reconstruction. Throwers that are considering MCL reconstruction should be aware of this, because it runs contrary to the ambitions of many younger athletes seeking MCL reconstruction in the hopes of not just continuing in their current level of competition, but ascending to a higher level of competition—something that seems very unlikely.

All Blogs, Baseball, Wrist/Hand

Madison Bumgarner’s Metacarpal Fracture

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On March 23, in a spring training game, a line drive fractured San Francisco Giants pitcher Madison Bumgarner’s small finger metacarpal on his pitching hand. He had surgery and is expected to miss four to six weeks. Bumgarner had surgery to realign and pin the fracture.

Metacarpal fractures don’t need surgery to heal, so there must have been substantial malalignment. The screws don’t help the fracture heal quicker, they just hold the bone aligned while it heals. After about a month, a metacarpal fracture doesn’t need any cast or splint support or immobilization. After three months, the bone is ready to take any level of force (about 80 to 90 percent strength). It takes a full year to get to 100 percent bone strength.

The decision to return to work or play is consideration of the risks and rewards. Doctors estimate a return to the mound at about six weeks.

This article was made by Aidan Jacobson and David Ring

All Blogs, Baseball, Elbow

Mark Melancon’s Pronator Syndrome

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The San Francisco Giants right hand pitcher Mark Melancon has stated he is day-to-day and will undergo surgery for pronator syndrome if his symptoms persist or at the end of the season.

What is pronator syndrome?
Pronator syndrome is a diagnosis that some doctors believe exists and others do not. The syndrome is troublesome forearm pain that is fairly diffuse and activity-related. Numbness is not one of the symptoms. The proposed pathophysiology is a compressive neuropathy in the front of the elbow or in the upper part of the forearm.

How do you diagnose pronator syndrome?
One of the sources of debate is that pronator syndrome cannot be confirmed by an objective test such as electrodiagnostic testing. The examination is normal except for imprecise and subjective things like tenderness and slight weakness resisting substantial force. Press reports indicate that Mark Melancon’s diagnosis of pronator syndrome was suggested by MRI findings, but there is no evidence that MRI can accurately and reliably diagnose pronator syndrome.

Why do some doctors use the diagnosis of pronator syndrome and others do not?
Non-specific, activity-related forearm pain is very common. For surgeons that believe in pronator syndrome, the “proof” is that patients feel better and thank them after surgery. However, people can be very resilient after surgery; even pretend or sham surgery. People can feel better and do more not because the surgery addressed an important problem, but because it gave them confidence and energy that allowed them to adapt. In research, we call this the placebo effect.

How could we determine if pronator syndrome is a useful diagnosis?
They only way to know if pronator syndrome is a useful diagnosis would be to compare real surgery and sham surgery and make sure the patient and evaluators had no way of knowing which one they got. Until we have a few such studies, people that have surgery for pronator syndrome are putting faith in what may be a social construction (a diagnosis that exists only because we behave as if it exists) and exposing themselves to the potential harm of surgery unnecessarily.

http://sites.utexas.edu/sports-blog/pitchers-elbow/ ‎

References: Rodner, C.M., B.A. Tinsley, and M.P. O’Malley, Pronator syndrome and anterior interosseous nerve syndrome. J Am Acad Orthop Surg, 2013. 21(5): p. 268-75.